Official Surgery Shelf Exam Discussion Thread

[VisionaryTics]

POD5 s/p I&D of inguinal sebaceous cyst, 57 yo male with 8 hr history of scrotal pain. PMH of DM2, CAD, hypercholesterolemia. Temp 102, HR 120, BP 90/50. PE shows scrotal edema and tenderness at base, 3cm black surgical incision with erythema extending to incision site. WMC 21k, 7% bands, Na 130, K 3.4, Glu 324. You give NS and insulin, whats the next best step?

a. warm compress
b hyperbaric O2
c. IV antifungal
d. IV K
e. surgical debridement

Obviously this is a surgery shelf and were looking at fourniers so debridement is the answer, but given the low K, wouldnt you want to give K with the insulin to prevent worsening of the hypokalemia?

You have somebody in florid septic shock from a surgical infection. Cut it out.

Remember this at 2am as a resident when you have a patient dying from a necrotizing soft tissue infection and anesthesia wants to spend a day optimizing electrolytes. Cut to save a life.

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[Misopogon]

You have somebody in florid septic shock from a surgical infection. Cut it out.

Remember this at 2am as a resident when you have a patient dying from a necrotizing soft tissue infection and anesthesia wants to spend a day optimizing electrolytes. Cut to save a life.

I havent taken the shelf and I will admit I havent really gone through this thread yet. But I have two quick questions I was hoping y'all could help me with. I have about 5 weeks left until my shelf which is plenty of time, I know. I have gone through Pestana (saving questions for the last few weeks), NMS, some FA surgery, and am now mainly focusing on questions.

With that said, I have not had my medicine rotation yet, and a lot of people have said there is a lot of medicine on this shelf. What is a good way to cover the medicine stuff? Is it sufficient to just read the texts I have read or should I consider looking at some other review books for medicine? For UW, what sections would you recommend for the medicine stuff?

Also, is pestana audio worth it? I have only read the book.

 

[doc0610]

hey guys, had a quick question, the form 1 of nbme CMS, the question with COPD, smoking history and cancer what is the answer? I chose small cell ca and got it wrong! I was wondering what else could that be. Yes, they are more prone to mesothelioma, but still lung cancer is more likely right?

the other options were,
1) mesothelioma
2) adenocarcinoma
3) large cell ca (undifferentiated)
4) squamous cell ca

 

[Señor S]

Don't know if this has been covered, but does anybody have any experience with the Kaplan QBank questions as prep for the Surgery shelf?

 

[CsHead]

hey guys, had a quick question, the form 1 of nbme CMS, the question with COPD, smoking history and cancer what is the answer? I chose small cell ca and got it wrong! I was wondering what else could that be. Yes, they are more prone to mesothelioma, but still lung cancer is more likely right?

the other options were,
1) mesothelioma
2) adenocarcinoma
3) large cell ca (undifferentiated)
4) squamous cell ca

SCC. Look at that Ca level.

 

[VisionaryTics]

hey guys, had a quick question, the form 1 of nbme CMS, the question with COPD, smoking history and cancer what is the answer? I chose small cell ca and got it wrong! I was wondering what else could that be. Yes, they are more prone to mesothelioma, but still lung cancer is more likely right?

the other options were,
1) mesothelioma
2) adenocarcinoma
3) large cell ca (undifferentiated)
4) squamous cell ca

Non-small cell lung cancer (squam/adeno) is still more common than SCLC. Pretty sure adeno is now slightly more common than squam, and if the patient was hypercalcemic, they're pointing to ectopic PTHrP secretion which is a paraneoplastic syndrome associated with squam.

 

[PL198]

thoughts on pestana audio?

 

[MirrorTodd]

thoughts on pestana audio?

I tried to listen to it, but I didn't get much out of it. Unless you're a great audio learner (which I am not, learned that through examkrackers way back when), you're gonna need the book in front of you to follow along with. The lectures are pretty long, so I sped them up with VLC and played them on 1.5 times.
The book was great for me...that plus doing the COMBANK and UWORLD questions about 1.5 times seemed to work out well for me. I'm DO though and I believe that our COMAT exams are fairly different that your shelf exams.

 

[J ROD]

Took it today. Was one of the harder ones. Had more than Surgery on it for sure. Some OB and def IM.

Lucky to have it last. Not expecting much from this one.

 

[blueshockey]

Had my test last Thursday. I'm not sure why it's called a surgery shelf because it certainly didn't feel like I was answering surgery questions! In all seriousness it had more to do with medical management of surgery with a few trauma questions, GI, and OBGYN mixed in. Lucky for me I haven't had internal or OB prior to this rotation so I obviously felt well prepared I used pestana, NMS, onlinemeded, and uworld but to be completely honest my step 1 prep was immensely more useful (not exaggerating) than any other resource. I would estimate 10-15 questions I got correct because of the aforementioned resources. I actually felt decent coming out of this test which was a nice change of pace. Raw was 88, correlated to the 98th percentile.

 

[cocoapelli]

Throwing in my 2 cents of experience:
I used Online MedEd + Pestana's book + Pestana audio + Uworld.
I'm a below average student, I got a (barely) above average score on the surgery shelf.

I thought Pestana's audio was much more helpful than the book. They cover the exact same topics, but the explanations were a little more detailed on the audio. I've been using Online MedEd for all my rotations since and I'm finding it to be a really excellent base of knowledge for each topic.
Congratulations everyone on getting through the rotation! Best of luck to those about to take the shelf!

 

[CodeRedDew]

Also throwing in my 2 cents of experience:
I used NMS Casebook + Pestana Audio/Book (audio = more helpful imo) + UWorld (Surgery + ~40 GI + ~40 renal/lytes)

Pestana is eh and I feel like is probably a little bit hyped up. The audio was good to listen to and went in a little more depth than the book, so if anything I'd definitely listen to the audio files. NMS Casebook is the money though, especially the three GI/hepatobiliary sections. Overall, studying for this exam is brutal given the demands of surgery, but here are some things I'd definitely focus on:

- GI diseases and their pre/post/peri-operative management (majority of my test)
- Vascular disorders
- Trauma/acute care surgery and management

And I had 1-2 questions each regarding other topics like OBGYN, endocrine, breast, etc. but the majority of my test were those three things above. The surgery section of UW is a little heavily focused on trauma (which is good) but I don't think it exposes to much of the other areas of surgery, so I definitely think you should at least do the GI sections + renal/lytes sections.

Score: 99th percentile (didn't give us our raw scores)

Happy studying! Shoot me a PM if you have any questions.

 

[theTruth_97]

so I was hoping someone could clarify the steps/tests one can pursue during neck trauma

In pestana it teaches that in zone I (base of neck) one can do arteriogram and triple endoscopy and in zone III an arteriogram is only option. In the amazing UT video the speaker says the opposite. I was wondering which one is right?

thanks in advance!

 

[ewax]

workup is basically the same in zone 1 and zone 3 trauma for the shelf...triple endoscopy and arteriogram.

 

[mcloaf]

Have 4 days left before the shelf. So far have done NMS casebook 1x (read this pretty early, fairly certain I have forgotten much of it), Pestana book x2, Pestana audio x1, Uworld surgery questions x1 + a few sets of Uworld IM GI, and both NBMEs yesterday (47/50 on each). I have already done my internal and OB rotations, which I feel is fairly helpful. I feel pretty prepared at this point but am wondering how best to spend my remaining time. I figure I'll redo some Uworld surgery questions, and I'm debating re-reading Pestana again vs trying to get through Casefiles vs re-reading some selected parts of NMS. Any input appreciated.

 

[ewax]

Have 4 days left before the shelf. So far have done NMS casebook 1x (read this pretty early, fairly certain I have forgotten much of it), Pestana book x2, Pestana audio x1, Uworld surgery questions x1 + a few sets of Uworld IM GI, and both NBMEs yesterday (47/50 on each). I have already done my internal and OB rotations, which I feel is fairly helpful. I feel pretty prepared at this point but am wondering how best to spend my remaining time. I figure I'll redo some Uworld surgery questions, and I'm debating re-reading Pestana again vs trying to get through Casefiles vs re-reading some selected parts of NMS. Any input appreciated.

lol, i think you're good bro.

 

[CodeRedDew]

Have 4 days left before the shelf. So far have done NMS casebook 1x (read this pretty early, fairly certain I have forgotten much of it), Pestana book x2, Pestana audio x1, Uworld surgery questions x1 + a few sets of Uworld IM GI, and both NBMEs yesterday (47/50 on each). I have already done my internal and OB rotations, which I feel is fairly helpful. I feel pretty prepared at this point but am wondering how best to spend my remaining time. I figure I'll redo some Uworld surgery questions, and I'm debating re-reading Pestana again vs trying to get through Casefiles vs re-reading some selected parts of NMS. Any input appreciated.

47/50 on both NBMEs... yeah I agree with above. I think you're good...lol

 

[mcloaf]

Heh ok then, I guess I'll just skim Pestana one more time and call it good. Thanks guys.

 

[mcloaf]

Felt much harder than NBMEs. Lots of muddy postop complication questions, not as much bread and butter GI path as I was expecting. A few questions I wouldn't have gotten without having already done medicine, psych, and OB rotations. I guess we'll see what happens in 6 weeks.

 

[mcloaf]

Felt much harder than NBMEs. Lots of muddy postop complication questions, not as much bread and butter GI path as I was expecting. A few questions I wouldn't have gotten without having already done medicine, psych, and OB rotations. I guess we'll see what happens in 6 weeks.

Ended up with a 92 raw score (we don't get percentiles). Wishing I could have a few of those questions back but overall pretty happy and hoping this can get me honors.

 

[CodeRedDew]

Ended up with a 92 raw score (we don't get percentiles). Wishing I could have a few of those questions back but overall pretty happy and hoping this can get me honors.

A 92 raw score is definitely 99th+ percentile so congrats! See, told you you were good lol

 

[pd1112]

Ended up with a 92 raw score (we don't get percentiles). Wishing I could have a few of those questions back but overall pretty happy and hoping this can get me honors.

The scale I have says that's 100th percentile, so you should be decent

 

[cbrons]

Felt much harder than NBMEs. Lots of muddy postop complication questions, not as much bread and butter GI path as I was expecting. A few questions I wouldn't have gotten without having already done medicine, psych, and OB rotations. I guess we'll see what happens in 6 weeks.

Yeah surgery NBME (took yesterday) seemed really tough. Way tougher than the NBME practice (form 2) I took a couple days before.

 

[Trogdor_The_Burninator]

Hello everyone,

Just wanted to post about the surgery shelf and what I thought was helpful.

I thought the exam was
- 30% medical management (pre-op/post-op) of common complications (e.g., patient will be getting adrenalectomy for a pheo, what pre-op meds do they get?; is this patient having an MI or PE?)
- 20% diagnosing what the patient has (e.g. patient has distended neck veins after trauma + a bunch of physical exam findings...what's the most likely diagnosis?)
- 20% questions that ask "what is the most likely outcome of (insert name of surgery/disease process)" or ask to identify a particular complication
- 5% choosing an imaging modality (CT v. MRI v. ultrasound, etc.), lab test, ...
- 5% on fluid/lytes management
- 5% on surgical nutrition
- 5% on surgical anatomy
- 5% questions that have to do with follow-up/screening
- 5% random q's that didn't fit into any of the above categories

Of note, there were 3-4 questions on OB (endometrial mass, ovarian torsion, ...), 8-10 questions on peds (congenital anomalies, ortho). Otherwise, there were quite a few questions on trauma, GI, and vascular surgery!

Sources I used:
- NMS casebook x 2 - presents cases with a lot of variations. It's a very helpful resource once you have the base knowledge down.
- NMS textbook x 1 - way too dense...had to force myself through this book once. This book has a lot of typos too and some sections are down-right irrelevant (most of the plastic surgery section, and some of the sub specialty sections)
- Step up to Surgery - riddled with typos. Some of my classmates used this book, but few got through the whole book. Lots of irrelevant info in this book too!
- Pestana's x 3 - Read about 3 times during the clerkship. Alone, not sufficient for the shelf at all, but can be read in a few hours and a good refresher.
- UW surgery x ? - Only ~130 q's. But redid some IM GI questions.

Sources I did not use:
- Surgical recall - I lost the book after my 3rd day on service...
- Pre-test - I'm not a fan of the pre-test series...

Outcome: >99th percentile (Raw 93)

I thought it really helped having medicine before surgery. I recommend to pick a source text (I like NMS over SU2S) and the NMS casebook. Pestana's is a quick easy read and I liked it a lot. UW is pretty trauma heavy, but has a few flowcharts in the answers that are indispensable for getting some of those trauma questions. I would recommend reviewing fluid and electrolyte management, and cardio, pulm, and GI medicine.

Some things to be able to differentiate (differentiating between these must become 2nd nature...): PE v MI, different types of vascular disorders (venous v arterial v diabetic and treatments for all of them), trauma scenarios (Tension Pneumo v. Pericardial tamponade v. cardiac contusion), most common causes of (insert favorite injury), most common complications of (insert favorite surgery), RtoL and LtoR shunts (some q's have 3 LtoR shunts, 1 RtoL shunt, and 1 other cause and the answer turns out to be the RtoL shunt), classic radiological/pathological findings (villous blunting and celiac, double bubble and duodenal atresia).

Good luck everyone! I hope this helped!

 

[Edentern11]

if you guys are interested, the devirgilio surgery kindle book is on sale for 7 bucks. i just snatched it up.

 

[bk_iq]

Is there a difference between Dr. Pestana's Surgery Notes: Top 180 Vignettes for the Surgical Wards (Second Edition) vs Kaplan Surgery Lecture notes?

Thanks

 

[pd1112]

Read most of Pestana, UW surgery x1 @ 98th percentile, got crushed on some UW Medicine, both Surg NBMEs 24 -> 83, lots of online meded, some Lawrence's Essentials & medscape here & there.
Shelf: 98th percentile. Thought it was ~ 25% gimmes straight from every resource with buzzwords, the rest seemed very difficult with all aspects of medicine + peds + OB/GYN + every surgical subspecialty well-represented. They basically look at almost every disease as potentially a surgical issue at some point, so what is the management at ___ stage & would make you choose between all of the conservative & surgical options you could imagine. Pretty true to actual medicine TBH, but wasn't expecting that degree of difficulty on a shelf exam. Thought it was substantially harder than IM & FM, yet I scored much better. I had a diverse clerkship with experiences in multiple subspecialties which I think helped immensely, because you won't find this material in any of the conventional surgery clerkship shelf exam resources. That being said, there were enough gimmes & gen surg that you could at least pass with the standard Pestana & UW. IMO Meded is an outstanding & highly underrated resource. The Lawrence books are still the GOATs for this shelf, but they read like typical textbooks, so I understand why most people can't stomach them.

 

[angldrps]

Is there a difference between Dr. Pestana's Surgery Notes: Top 180 Vignettes for the Surgical Wards (Second Edition) vs Kaplan Surgery Lecture notes?

Thanks

NO difference at all. They are exactly the same.

 

[angldrps]

took this not too long ago, so here's my input:

resources for content review from most helpful to least: onlinemeded videos+notes > pestana> NMS casebook
resources for questions from most helpful to least: onlinemeded question bank (must have subscription for this) = uworld IM questions > pretest > u world surgery questions

Everyone raved about NMS case book, but instead of reading this, do uworld IM questions on the topics in NMS (GI, renal, electrolytes, endocrine)

I can't rave enough about onlinemeded. the videos that are surgery specific go over all the relevant IM topics, which was more helpful than pestana or NMS casebook.

I would not have passed had I only done surgery specific questions. What saved me was doing all those IM questions in uworld and onlinemeded Q bank. Good luck everyone!

 

[pizza4u]

Has anyone taken Form 4 NBME practice shelf and know how it compares to the shelf?

I've taken the shelf already but never did any of the NBME practice tests to prep. I'm studying with a friend and went over some of the questions with him. I thought they seemed harder than the shelf so I'm hoping I can reassure him that he's doing fine!

 

[Hangry]

Resources-

Uworld 1x (surgery and GI sections) + incorrects
Pestana book 1x
Onlinemeded 1-2x
Pestana audio 2x

Raw score 85+. Not my best performance, probably related to being burnt out as **** for the last ten days or so of the rotation. Thought pestana audio was way more valuable than the book content wise (always easier to understand reasoning than try to memorize bullet points). And considering surgery is most people's most time-crunched rotation, being able to study while doing other things (driving, chores, running) is a massive benefit. Tried to dabble in a few other resources (eg NMS casebook) but thought it was terrible. Surgical recall periodically for pimping but not for shelf review.

 

[purpledragon1]

Anyone know the answer to this question? Comes from form 1:

25 y.o. woman diagnosed with ectopic pregnancy. During surgery, woman was found not to have ectopic pregnancy but instead had appendicitis, which was removed during the same surgery. The permit only allowed surgery for the presumed ectopic pregnancy. Which one describes the surgeon's conduct?

A) Appropriate because removing inflamed appendix was medically necessary
B) Appropriate only if spouse consented
C) Inappropriate b/c this is an unauthorized extension of field of surgery
D) Inappropriate b/c pt not informed of risks of appendectomy

I put C but this was wrong. I'm pretty sure it's not B, so the answer is probably A or D. Any help? Thanks.

 

[pd1112]

Anyone know the answer to this question? Comes from form 1:

25 y.o. woman diagnosed with ectopic pregnancy. During surgery, woman was found not to have ectopic pregnancy but instead had appendicitis, which was removed during the same surgery. The permit only allowed surgery for the presumed ectopic pregnancy. Which one describes the surgeon's conduct?

A) Appropriate because removing inflamed appendix was medically necessary
B) Appropriate only if spouse consented
C) Inappropriate b/c this is an unauthorized extension of field of surgery
D) Inappropriate b/c pt not informed of risks of appendectomy

I put C but this was wrong. I'm pretty sure it's not B, so the answer is probably A or D. Any help? Thanks.

A
No one refuses surg for appendectomy, informed consent is assumed.

 

[PL198]

A
No one refuses surg for appendectomy, informed consent is assumed.

huh? that makes no sense. they absolutely could refuse and just want to try antibiotics and IVF first.

I look at it as urgent but not emergent. so I would put D

Don't really understand how you're looking at this, nothing is ever assumed, it's just emergency vs non-emergency

 

[Trogdor_The_Burninator]

Anyone know the answer to this question? Comes from form 1:

25 y.o. woman diagnosed with ectopic pregnancy. During surgery, woman was found not to have ectopic pregnancy but instead had appendicitis, which was removed during the same surgery. The permit only allowed surgery for the presumed ectopic pregnancy. Which one describes the surgeon's conduct?

A) Appropriate because removing inflamed appendix was medically necessary
B) Appropriate only if spouse consented
C) Inappropriate b/c this is an unauthorized extension of field of surgery
D) Inappropriate b/c pt not informed of risks of appendectomy

I put C but this was wrong. I'm pretty sure it's not B, so the answer is probably A or D. Any help? Thanks.

I heard about this question from one of my friends and I had no idea as well. She said that it was related to "therapeutic privilege" but that didn't make much sense to me... Can someone please explain this?

 

[pd1112]

huh? that makes no sense. they absolutely could refuse and just want to try antibiotics and IVF first.

I look at it as urgent but not emergent. so I would put D

Don't really understand how you're looking at this, nothing is ever assumed, it's just emergency vs non-emergency

I already took this test. The answer is A.

I didn't mean to come off as black-and-white dx appendicitis -> surgery without exception. But in this situation, for the nbme and probably 99.99% of the time in real life, appendectomy is an adjunct procedure to any ex. lap. that is acceptable, particularly in the setting of appendicitis, unless the patient specifically states that he/she refuses it before the procedure begins and it's written that way on the consent. In this setting, it's medically necessary because it's the accepted standard of care and you've already opened up the abdomen, so closing them up and going back in after another consent with all of the risks of an additional surgery wouldn't be acceptable. You can't presume that she's stable and it's only a mild appendicitis, because you aren't given that information. Appendectomy is standard of care in the US and there's no convincing data to state otherwise, particularly with the limited clinical information in this question. The NBME isn't going to test on nonstandard care unless it states the patient refuses the standard. The operation in this presumed emergent case is 1. ex lap 2. anything else, so even though the consent doesn't say "appendectomy" the procedure is implied for what is determined to be medically necessary - hence, "ex lap."

 

[mcloaf]

What's on the CXR?

 

[VitaminD_1]

There is a slight opacification in the rt mid lung field but no signs of tracheal shift as one would expect in atelectasis. But even if we take xray out of the picture atelectasis never presents with EGOPHONY AND DULNESS. she also has a low grade fever so looks more like pneumonia to me

 

[purpledragon1]

Hey guys, I have some questions from the Surgery NBME form 3 I need help with.

1. 55 yo man goes to ED 1 hour after onset of vomiting and severe substernal pain radiating to back, which began after eating a large meal. He is diaphoretic. BP 90/70. Serum amylase normal. ECG and x-rays of abdomen normal. Chest x-ray shows blunting of left costophrenic angle. Esophagography with contrast shows leakage into the mediastinum and left pleural cavity. IVF and abx started. Most appropriate next step?
a) Esophagoscopy
b) Exploratory celiotomy
c) Exploratory thoracotomy
d) CT scan of chest
e) Tube thoracostomy
This sounds like esophageal rupture to me. I picked B which was wrong. Is it c?

2. 32 yo woman comes to ED due to 10 hrs of increasingly severe constant pain in abdomen. Has nausea. Has lupus controlled w/ prednisone. T100.4, pulse 110, resp 16, BP 115/65. No scleral icterus. Abdomen soft and tender over RUQ, with mild guarding, no rebound.
Hb 14, leukocytes 12,000 (neutrophils 75%, bands 10%, lymphocytes 15%).
LFTs normal. Abdominal ultrasound show distended gallbladder w/ thick wall and stone in neck of gallbaldder. Given cefazolin and IV ringer solution and taken for lap chole. On induction with propofol, BP decreases to 60/40 and stays there despite 500-mL bolus of lactated ringer solution. Most appropriate next step in pharmacotherapy?
a) Give diphenhydramine
b) give dopamine
c) give gentamicin
d) give hydrocortisone
e) decrease dose of propofol
I chose E but it was incorrect.

3. 16 yo girl brought to ED after being stabbed in anterior neck 30 minutes ago. Large hematoma visualized and pulsatile at level of thyroid cartilage. Hematoma is expanding. Most appropriate initial step?
a) barium esophagography to rule out esophageal injury
b) endotracheal intubation
c) esophagoscopy to rule out esophageal injury
d) indirect laryngoscopy is determine vocal cord injury
e) tracheostomy
I chose E which was wrong. I don't think it's a, c, or d, which leaves b. Is it b? I was thinking the hematoma could block the airway so would need to do a trach. I went with tracheostomy b/c there was a very similar question in form 2 about a patient needing an airway but had neck tumors and the answer was trach. Could someone explain this question?

4. 57 yo woman has 3-mo hx of cough which has become more frequent in past month. Had blood-tinged sputum once. No other symptoms. Smoked a pack a day for 40 years. BMI 26. Coarse rhonchi over right lung base. Chest x-ray shows 3-cm mass near hilbum of right lung. Biopsy shows non-small cell carcinoma in right main stem brochus. No metastatic disease. Preoperative testing:
FEV1 for left lung - 600 mL
Maximum voluntary ventilation (MVV) - 50% of predicted
Diffusion capacity of lung for carbon monoxide (DLCO) - 50% of predicted
ABG:
PCO2 - 44 mm Hg
PO2 - 75 mm Hg
Which parameter is most likely to be useful in assessing pt's post-op risk for pneumonectomy?
a) Arterial blood PCO2
b) Arterial blood PO2
c) DLCO
d) FEV1
e) MVV
I picked C, which is wrong. Is it d?

 

[stepone2015]

Hey guys, I have some questions from the Surgery NBME form 3 I need help with.

1. 55 yo man goes to ED 1 hour after onset of vomiting and severe substernal pain radiating to back, which began after eating a large meal. He is diaphoretic. BP 90/70. Serum amylase normal. ECG and x-rays of abdomen normal. Chest x-ray shows blunting of left costophrenic angle. Esophagography with contrast shows leakage into the mediastinum and left pleural cavity. IVF and abx started. Most appropriate next step?
a) Esophagoscopy
b) Exploratory celiotomy
c) Exploratory thoracotomy
d) CT scan of chest
e) Tube thoracostomy
This sounds like esophageal rupture to me. I picked B which was wrong. Is it c?


The pathology is in the chest, but you want to open the abdomen? C.

2. 32 yo woman comes to ED due to 10 hrs of increasingly severe constant pain in abdomen. Has nausea. Has lupus controlled w/ prednisone. T100.4, pulse 110, resp 16, BP 115/65. No scleral icterus. Abdomen soft and tender over RUQ, with mild guarding, no rebound.
Hb 14, leukocytes 12,000 (neutrophils 75%, bands 10%, lymphocytes 15%).
LFTs normal. Abdominal ultrasound show distended gallbladder w/ thick wall and stone in neck of gallbaldder. Given cefazolin and IV ringer solution and taken for lap chole. On induction with propofol, BP decreases to 60/40 and stays there despite 500-mL bolus of lactated ringer solution. Most appropriate next step in pharmacotherapy?
a) Give diphenhydramine
b) give dopamine
c) give gentamicin
d) give hydrocortisone
e) decrease dose of propofol
I chose E but it was incorrect.

D. She needs stress dose steroids.

3. 16 yo girl brought to ED after being stabbed in anterior neck 30 minutes ago. Large hematoma visualized and pulsatile at level of thyroid cartilage. Hematoma is expanding. Most appropriate initial step?
a) barium esophagography to rule out esophageal injury
b) endotracheal intubation
c) esophagoscopy to rule out esophageal injury
d) indirect laryngoscopy is determine vocal cord injury
e) tracheostomy
I chose E which was wrong. I don't think it's a, c, or d, which leaves b. Is it b? I was thinking the hematoma could block the airway so would need to do a trach. I went with tracheostomy b/c there was a very similar question in form 2 about a patient needing an airway but had neck tumors and the answer was trach. Could someone explain this question?

B. Rapidly expanding neck mass = threat of airway collapse. If you try to intubate and can't get it and patient is desatting, then cric. Trach is done in the OR and never done as an emergency procedure. Trachs are more difficult than crics.

4. 57 yo woman has 3-mo hx of cough which has become more frequent in past month. Had blood-tinged sputum once. No other symptoms. Smoked a pack a day for 40 years. BMI 26. Coarse rhonchi over right lung base. Chest x-ray shows 3-cm mass near hilbum of right lung. Biopsy shows non-small cell carcinoma in right main stem brochus. No metastatic disease. Preoperative testing:
FEV1 for left lung - 600 mL
Maximum voluntary ventilation (MVV) - 50% of predicted
Diffusion capacity of lung for carbon monoxide (DLCO) - 50% of predicted
ABG:
PCO2 - 44 mm Hg
PO2 - 75 mm Hg
Which parameter is most likely to be useful in assessing pt's post-op risk for pneumonectomy?
a) Arterial blood PCO2
b) Arterial blood PO2
c) DLCO
d) FEV1
e) MVV
I picked C, which is wrong. Is it d?

A.

 

[purpledragon1]

@stepone2015 Thanks! Could you explain the last one? I'm not really even sure what the question is asking. Is it asking for which one would be the best predictor for decreased morbidity and mortality after pneumonectomy?

 

[purpledragon1]

One more question from form 3!

8 hrs after transurethral prostate resection, 62 yo has hemoglobin of 7.5. Transfusion of heterologous packed RBCs begun. 2 hrs later, he has fever and chills. Received 200mL. Temp is 39c (102.2F), pulse 120, pulse 18, BP 120/70. Explanation?
a) ABO incompatibility
b) bacterial overgrowth in transfused blood
c) intravenous cathether infection
d) preformed antibodies to leukocyte antigens
e) Rh incompatibility

I put A as the answer but it was wrong.

 

[stepone2015]

@stepone2015 Thanks! Could you explain the last one? I'm not really even sure what the question is asking. Is it asking for which one would be the best predictor for decreased morbidity and mortality after pneumonectomy?

It is basically, but I don't understand the pathophys for that one. I just know the answer based of off Uptodate. It's also a pimp question I've heard about.

 

[stepone2015]

One more question from form 3!

8 hrs after transurethral prostate resection, 62 yo has hemoglobin of 7.5. Transfusion of heterologous packed RBCs begun. 2 hrs later, he has fever and chills. Received 200mL. Temp is 39c (102.2F), pulse 120, pulse 18, BP 120/70. Explanation?
a) ABO incompatibility
b) bacterial overgrowth in transfused blood
c) intravenous cathether infection
d) preformed antibodies to leukocyte antigens
e) Rh incompatibility

I put A as the answer but it was wrong.

D. ABO would be instant signs of hemolysis ie red urine.

 

[purpledragon1]

D. ABO would be instant signs of hemolysis ie red urine.

Thanks! Do you know why he would have preformed antibodies against leukocyte antigens found in the transfused blood? Are we assuming that he has had transfusions from the same source previously, causing him to produce antibodies against the antigens found in the blood?

 

[rollingstone27]

Hey guys, I have some questions from the Surgery NBME form 3 I need help with.

1. 55 yo man goes to ED 1 hour after onset of vomiting and severe substernal pain radiating to back, which began after eating a large meal. He is diaphoretic. BP 90/70. Serum amylase normal. ECG and x-rays of abdomen normal. Chest x-ray shows blunting of left costophrenic angle. Esophagography with contrast shows leakage into the mediastinum and left pleural cavity. IVF and abx started. Most appropriate next step?
a) Esophagoscopy
b) Exploratory celiotomy
c) Exploratory thoracotomy
d) CT scan of chest
e) Tube thoracostomy
This sounds like esophageal rupture to me. I picked B which was wrong. Is it c?

2. 32 yo woman comes to ED due to 10 hrs of increasingly severe constant pain in abdomen. Has nausea. Has lupus controlled w/ prednisone. T100.4, pulse 110, resp 16, BP 115/65. No scleral icterus. Abdomen soft and tender over RUQ, with mild guarding, no rebound.
Hb 14, leukocytes 12,000 (neutrophils 75%, bands 10%, lymphocytes 15%).
LFTs normal. Abdominal ultrasound show distended gallbladder w/ thick wall and stone in neck of gallbaldder. Given cefazolin and IV ringer solution and taken for lap chole. On induction with propofol, BP decreases to 60/40 and stays there despite 500-mL bolus of lactated ringer solution. Most appropriate next step in pharmacotherapy?
a) Give diphenhydramine
b) give dopamine
c) give gentamicin
d) give hydrocortisone
e) decrease dose of propofol
I chose E but it was incorrect.

3. 16 yo girl brought to ED after being stabbed in anterior neck 30 minutes ago. Large hematoma visualized and pulsatile at level of thyroid cartilage. Hematoma is expanding. Most appropriate initial step?
a) barium esophagography to rule out esophageal injury
b) endotracheal intubation
c) esophagoscopy to rule out esophageal injury
d) indirect laryngoscopy is determine vocal cord injury
e) tracheostomy
I chose E which was wrong. I don't think it's a, c, or d, which leaves b. Is it b? I was thinking the hematoma could block the airway so would need to do a trach. I went with tracheostomy b/c there was a very similar question in form 2 about a patient needing an airway but had neck tumors and the answer was trach. Could someone explain this question?

4. 57 yo woman has 3-mo hx of cough which has become more frequent in past month. Had blood-tinged sputum once. No other symptoms. Smoked a pack a day for 40 years. BMI 26. Coarse rhonchi over right lung base. Chest x-ray shows 3-cm mass near hilbum of right lung. Biopsy shows non-small cell carcinoma in right main stem brochus. No metastatic disease. Preoperative testing:
FEV1 for left lung - 600 mL
Maximum voluntary ventilation (MVV) - 50% of predicted
Diffusion capacity of lung for carbon monoxide (DLCO) - 50% of predicted
ABG:
PCO2 - 44 mm Hg
PO2 - 75 mm Hg
Which parameter is most likely to be useful in assessing pt's post-op risk for pneumonectomy?
a) Arterial blood PCO2
b) Arterial blood PO2
c) DLCO
d) FEV1
e) MVV
I picked C, which is wrong. Is it d?

1. I got it wrong also but with some reading, I think the answer is E. You want to prevent the impending tension pneumothorax

4. I put D and got it right.

 

[purpledragon1]

I also have some questions on form 3 if someone wouldn't mind helping out, thanks:

Form 3:
1. 26 yo woman with worsening abdominal cramps. Intermittent diarrhea and 5kg weight loss. Generalized tenderness, hyperactive bowel sounds, no guarding. Pronounced tenderness and mass in right lower quadrant. Barium enema exam shown:
a. amebic enteritis
b. crohn
c. leiomyosarcoma
d. necrotizing enterocolitis
e. recurrent intussusception

E is wrong. Maybe B?

This is Crohn disease. Symptoms typical of inflammatory bowel disease including cramping, diarrhea, weight loss, fever. Crohns can cause mass in lower right quadrant (read this one uptodate).

2. 32 yo female. Shows for symptoms of acute cholecystitis and goes to OR for lap chole. She was given cefazolin and IV LR. With induction of propofol, blood pressure drops to 60/40 and remains constant despite admin of 500ml bolus. What to do next?
a. diphenhydramine
b. dopamine
c. gentamicin
d. hydrocortisone
e. decrease propofol

Answer is D, she is on long-term prednisone therapy and adrenals can't produce enough cortisol to respond to stressful state (surgery).

3. Jehovah’s witness is 2 days post op for valve replacement. She needs blood but she explicitly stated she wanted no blood products before surgery, under no circumstances. Whats next?

a. sign dnr oder
b. give erythropoietin, IV
c. iron IM
d. transfuse rbc
e. ex lap

Ex lap since she is bleeding from abdomen. b and c are not fast enough to produce a response in someone rapidly decompensating.

4. 64 M has frequent PVC after elective hernia repair and has spinal anesthesia T3-T4 motor and sensory block. Pulse ox is 95, unchanged from pre op.

ABG:
Ph 7.25
Pco2 55
Po2 75

EKG: normal sinus and PVC. Why?

a. fluid overload
b. intra op MI
c. metabolic acidosis
d. total sympathetic blockade
e. ventilator insufficiency

e, since hypercapnia can cause PVCs.

not C, possibly E?

 

[pd1112]

1. I got it wrong also but with some reading, I think the answer is E. You want to prevent the impending tension pneumothorax

It's esophageal rupture. Need thoracotomy to fix the tear (c), just a tube won't help.

3. Jehovah’s witness is 2 days post op for valve replacement. She needs blood but she explicitly stated she wanted no blood products before surgery, under no circumstances. Whats next?

a. sign dnr oder
b. give erythropoietin, IV
c. iron IM
d. transfuse rbc
e. ex lap

Ex lap since she is bleeding from abdomen. b and c are not fast enough to produce a response in someone rapidly decompensating.

Patient had a valve replacement and is bleeding from the abdomen?

 

[purpledragon1]

It's esophageal rupture. Need thoracotomy to fix the tear (c), just a tube won't help.



Patient had a valve replacement and is bleeding from the abdomen?

I don't remember the exact question but there was more information indicating that she could have been bleeding from her abdomen.

 

[nolamed13]

@stepone2015 Thanks! Could you explain the last one? I'm not really even sure what the question is asking. Is it asking for which one would be the best predictor for decreased morbidity and mortality after pneumonectomy?

@purpledragon1 The answer is D, FEV1. A preoperative FEV1 of >1500 for lobectomy and >2000 for pneumonectomy generally indicates suitability. Values less than this should prompt further investigation of respiratory function.